Penetrating trauma to the neck

Penetrating injuries to the neck can cause threatening injuries and damage to many vital structures. Injury patterns associated with penetrating neck trauma are multiple and varied ranging from soft tissue injury to spinal cord transection. Without hard clinical signs such as stridor, dysphagia, or an expanding hematoma, the diagnosis of vital structure injury can be difficult. In the presence of clinically subtle signs or minimal symptoms, adjunctive modalities such as angiography, endoscopy and oesophagography have increased the accuracy in diagnosing these injuries. The routine use of these modalities remains controversial. A retrospective review was performed of 18 patients with penetrating trauma to the neck, evaluated by the Trauma Service of Morehouse School of Medicine, Department of Surgery from July 1994 to July 1997. The injury patterns of the 17 patients who survived more than twenty-four hours were evaluated. Nine patients (53 percent) had injuries to vital structures within the neck, which included: spinal cord injury (3): vascular injury (3); oesophageal injury (1); tracheal injury (1); thyroid cartilage injury (1); and hyoid bone fracture (1). Seven patients had neck explorations and three had no evidence of vital structure injury. Eight patients were evaluated with panendoscopy. Six of these had negative studies, and the two patients with positive studies had injuries noted prior to endoscopy which required operative intervention. Ten patients had oesophagrams which were all negative, and vascular injuries were detected in three of the six patients in whom this procedure was undertaken. The mean hospital stay for all patients was 14.8 days, but this was longer for patients with neck injuries (22.9 days) than for those without neck injury (5.8 days). The average length of stay in the Intensive Care Unit was 6.24 days. Patients with neck injuries had a mean length of stay of 11.6 days compared to those without neck injury whose mean stay was less than one day. In conclusion: (1) angiography remains an important diagnostic tool in the evaluation of patients with penetrating neck trauma; (2) without clinical evidence of vital structure injury, panendoscopy and oesophagography may not be necessary in the routine evaluation of patients with penetrating neck trauma; (3) selective surgical intervention remains an important tool in the evaluation and management of patients with penetrating neck trauma.(AU)

Cavernous haemangioma of the duodenum: a rare case of gastrointestinal bleeding

Vascular malformations (VMs), including haemangioma, of the upper gastrointestinal tract, are rare causes of bleeding. Bleeding from these lesions is often recurrent and diagnosis is often delayed for months to years. A patient with severe, recurrent upper gastrointestinal bleeding requiring repeated hospitalization and blood transfusions is presented. Upper endoscopy, barium meal and small bowel enteroclysis were negative. Selective mesenteric angiography revealed a VM in the second part of the duodenum. Segmental resection of the duodenum was performed and microscopial examination showed cavernous haemangioma. VM should be considered in patients with recurrent gastrointestinal bleeding and negative conventional investigations. Mesenteric angiography may be the only investigation which will identify these leisons. Results after excision are excellent. (AU)

A review of the initial two years of a cardio-diagnostic programme in a small island community - abstract

In January 1982, regular right and left cardiac catheterizations and angiography, and detailed examination of cardiac structures in dynamic motion by Real Time (2-D) echocardiography were started at the QEH. During the past 2 years, 64 patients - 45 from Barbados, 7 from St. Lucia, 4 each from Dominica and Trinidad, 3 from Grenada and 1 from Antigua (age 3 weeks to 64 years) underwent cardiac catheterization and angiography with no mortality and minimal morbidity. All of the patients had Real-Time Echocardiography prior to catheterization, and the correct (catheterization) diagnosis was made in all but 5 cases. Thirty-one patients have undergone cardiac surgery - 17 at North Shore University Hospital in New York by special arrangement whereby there was no cost or nominal cost to the patient: 3 at the hospital of their choice in North America; 5 at UHWI in Jamaica, and 6 at the QEH. Eight of the 17 patients going to North Shore have been recatheterized, and our echo and catheterization diagnoses remained unchanged. The other 9 patients underwent surgery without recatheterization, and our echo and catheterization data were confirmed at surgery. There have been 2 operative deaths and 2 late deaths. All of the other post surgical patients are significantly improved and most are living normal or near normal lives. This Report shares the initial 2 years' experience of a Cardio-Diagnostic programme at the QEH, and the subsequent surgical results. Real-time (2-D) echocardiography in our hands has been accurate (92 percent of the time); cardiac catheterization has been safe; and the surgical results are satisfying (AU)

On the role of tortuous coronary arteries in billowing mitral leaflet syndrome: a hypothesis

Sixty three male patients with billowing mitral leaflet syndrome (BML) and forty one age and sex match controls were studied with emphasis on the cineangiographic features of coronary arteries. In the BML group, the coronary arteries were considered normal in five and abnormal in fifty eight. In fifty eight with abnormal coronary arteries, twelve showed atherosclerotic occlusive lesion, fifteen showed combined occlusive lesions and nonocclusive abnormalities and thirty one showed nonocclusive abnormalities alone. The non-atherosclerotic abnormalities consisted of redundancy of the coronary arteries manifested by bizarre changes in configruation and motion. These abnormalities were present in only five patients in the control group. On the basis of our observations and corroborative evidence in the literature, a hypothesis is presented; the salient features of which are that: (1) the spectrum of BML may be considerably more complex than hitherto suspected, (2) a combination of BML and tortuous coronary arteries may form a distinct subset of this spectrum and (3) the increased tortuousity may result in impaired coronary perfusion causing myocardial ischemia thus offering a possible explanation for some of the symptoms- such as chest pain, arrhythmias and even sudden death seen in this syndrome. (AU)

The dangers in the use of intravascular contrast media during radiological investigations

The complications and dangers encountered when contrast media are injected into the vascular system are discussed. Suggestions are given in an effort to reduce the incidence of these complications, thereby making these radiological investigations safer for the patient (AU)

Intralobar pulmonary sequestration in association with bilateral systemic arterialization of the lungs

Over 250 cases of intralobar pulmonary sequestration have now been reported (Ranniger and Valvassori, 1964). The diagnosis which may be suscepted on the clinical, plain radiograph and bronchographic findings, depends on the angiographic or operative demonstration of an aberrant systemic arterial supply to the affected segment. The preoperative angiographic visualization of this pulmonary systemic arterialization arising from the thoracic or abdominal aorta either as a single large vessel (McDowell, Robb, and Indyk, 1955) or as multiple small arteries (Turk and Lindskog, 1961) to a large extent eliminates the operative hazards (Harris and Lewis, 1940). This paper reports an unusual case of pulmonary intralobar sequestration in association with bilateral aberrant systemic arteries. The angiographic and operative findings suggest that this may be a case of bilateral pulmonary sequestration (Summary)

Radiological observation on an alveolar soft-part sarcoma complicated by trauma and myositis ossificans

The alveolar soft-part sarcoma is a rare tumour that has recently been identified. It resembles chemodectomas and arises from primitive nerve cells. It differs from chemodectomas in its location and in its more malignant behaviour. The tumour was highly vascular and similar in appearance to chemodectomas. The author's patient complained of symptoms after an injury that was complicated by the development of myositis ossificans. The possible relationship between trauma and the development of the tumour is discussed. (AU)

Idiopathic cardiomegaly

Cardiomyopathies are certain heart diseases of unknown etiology and pathogenesis, occurring mostly in tropical and subtropical areas, where they constitute a major clinical problem and sometimes a public health problem. The need for international co-operation in the study of such forms of heart diseases has long been recognized and WHO convened informal meetings of investigators on various aspects of the subject in 1964, 1965 and 1966. Out of these have arisen co-operative studies co-ordinated by WHO. In November 1967 a fourth informal meeting was held in Kingston, Jamaica, to review the following topics: the progress reports from all co-operating laboratories; the diferent types of cardiomyopathies; past experience with cardiac registries, and the diagnostic importance of coronary angiography. Steps were taken towards the formulation of a standard terminology, since too many confusing names are currently employed to mean "cardiomegaly of unknown origin". A common name, "idiopathic cardiomegaly", was therefore suggested for further use. The account presented here was prepared by Dr. Z. Fejfar, Chief Medical Officer, Cardiovascular Diseases, World Health Organization, Geneva, on behalf of the other participants and is a precis of some of the information that was exchanged, some of the views that were expressed and of the suggestions that were made.(AU)

Two emergency femoral arteriograms: radiological case report

The value of femoral arteriography performed as an emergency procedure is illustrated by two cases. The first case was an aneurysm of the lower femoral artery which had ruptured and produced acute ischaemic changes in the affected limb. The second case of a varicose aneurysm was due to a gun-shot wound in the thigh. The aneurysm presented clinically as an abscess. Surgical excisison and repair of the aneurysm was performed in each case (AU)

Some clinical aspects of subarachnoid haemorrhage

Two hundred and forty-six cases of "subarachnoid haemorrhage" admitted to a general hospital over a five year period (1952-56) are presented, of which 190 were treated "medically" and 56 "surgically". The results are compared. If patients dying within the first 24 hours of admission to hospital are excluded, the comparison between those treated medically and surgically is quite favourable towards "conservatism", confuting the generally quoted figures which usually have a decided bias towards surgery and are too often derived from selected groups. Patients with persisting symptoms and signs, or with a secondary rise in pulse rate and recurrence of signs and symptoms should be promptly investigated by angiography and sent to surgery. Non-ganglion blocking hypotensive drugs should be considered in the hypertensive subject. A plea is made for a more rational approach to the problem, particularly in centres where they are admitted to the wards of a general hospital. (AU)